Health Information Management

Topic: Improve coding quality

HIM-HIPAA Insider, May 8, 2007

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Improve your documentation simply by using effective queries or by initiating a comprehensive reeducation of clinicians. Because documentation is the basis for many claim denials, the Office of Inspector General (OIG) monitors payments that cannot be substantiated by the documentation in the patient record.

Although 30% of the documentation errors of omission or insufficiency fall in the improper payment category of the OIG's report, medical necessity denials (medically unnecessary services) account for nearly 60% of the improper payments and are often the result of missing diagnoses or not having enough documentation to support the necessity of a service.

Physician documentation expert Robert S. Gold, MD, says "The goal of a physician query is to achieve a better reflection of the true disease process by assigning the best code for the clinical situation." Coding professionals should use the physician query to clarify such issues as the following:

  • Discrepancies or ambiguities in documentation (e.g., one notation indicates a condition and another states the condition was not present)
  • Whether there has been treatment for conditions that are not noted in the physician's documentation (e.g., routine glucose monitoring but no mention of diabetes or other condition that would require such monitoring)
  • Causes of conditions (e.g., osteoporosis as the cause of a pathological fracture)
  • Refinement of conditions by securing qualifiers (e.g., type of hypertension)
  • The American Health Information Management Association (AHIMA) published guidance on creating nonleading queries in an October 2001 practice brief, "Developing a Physician Query process." In this brief, author Susan prophet, RHIA, CCS, states,

    Physician documentation is the cornerstone of accurate coding. Therefore, assuring the accuracy of coded data is a shared responsibility between coding professionals and physicians. Accurate diagnostic and procedural coded data originate from collaboration between physicians, who have a clinical background, and coding professionals, who have an understanding of classification systems.

    Ensuring data quality and integrity also are HIM responsibilities. To do so, HIM professionals must seek clarification from the clinicians. The coding professional must avoid "leading the physician" when seeking clarification. This means that the query must ask about documented comments or results, rather than suggest that the results may be related to a condition.

    Tune in next week to read more about how your HIM department should establish a policy that addresses how and when it will use query forms.

    Editor's note: The above article was adapted from the book Coder Productivity: Tapping your Team's Talents to Improve Quality and Reduce Accounts Receivable. For more information or to order, call 877/727-1728 or click here

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